04/28/12

Abou-Elhamd

Otalgia

Dr. Kamal Abou-Elhamd MD Professor in ENT Al-Ahsa College of Medicine King Faisal University
04/28/12 Abou-Elhamd 2

Otalgia
Otalgia is a common presenting symptom to the ENT clinic The aetiology of otalgia can be divided into Otological and Non otological (50% of cases) Non otological: referred, neuralgia or psychogenic pain

Otalgia
Referred otalgia is a difficult diagnostic challenge to even the most experienced otolaryngologist As a result of the high possibility of referred ear pain being caused by an upper aerodigestive tract malignancy, to many physicians a painful, normal ear equals a head and neck malignancy until proven otherwise

Todd J. Scarbrough, Terry A. Day, Todd E. Williams, James H. Hardin, Eric G. Aguero, and Charles R. Thomas: Referred Otalgia in Head and Neck Cancer Am J Clin Oncol 2003;26: e157e162

History
Having excluded otological causes of otalgia by the absence of other ear symptoms (otorrhoea, itchiness, hearing loss, vertigo and tinnitus) and Normal otoscopy supplemented by tympanometry and audiometry where indicated the following is the recommended strategy for questioning, investigating and managing a patient with referred otalgia

History
Ask about onset and duration: A sharp lancinating pain in a unilateral sensory distribution with known trigger zones is suggestive of neuralgia (trigeminal). A burning, electric shocktype pain triggered by swallowing is suggestive of glossopharyngeal neuralgia. A unilateral chronic dull boring pain in a patient with known risk factors (age >50, smoking and excessive alcohol intake) could indicate an underlying malignant lesion in the pharynx (tongue base, tonsil and piriform fossa) or larynx.

History
Ask about specific aggravating factors: Otalgia aggravated with biting or chewing is suggestive of temporomandibular joint dysfunction (TMD)(35% of referred otalgia). Eighty five percentage of patients with TMD present with ear symptoms such as otalgia, aural fullness or tinnitus

History
Ask about symptoms suggestive of dental disease: Dental disorders (caries, abscess, periodontitis and malocclusion) are the most common causes of referred otalgia (50% of referred otalgia)

History
Ask about co-existing nasal symptoms: Symptoms of nasal obstruction, rhinorrhoea or post-nasal drip should be elicited as chronic rhinosinusitis can cause otalgia secondary to eustachian tube dysfunction. Ask about recent surgical procedures: Dental procedures (fillings and extractions) are common causes of referred otalgia. Post-tonsillectomy patients can experience otalgia in the early postoperative period

History
Ask about co-existing symptoms of the upper aerodigestive tract: Otalgia associated with a sore throat or odynophagia can be secondary to acute infections such as tonsillitis, peritonsillar abscess or pharyngitis. Otalgia associated with dysphagia, hoarse voice or weight loss is suspicious of malignant lesions in the upper aerodigestive tract. The literature reports up to 57% of patients with nasopharyngeal carcinoma complain of otalgia compared with 26% with hypopharyngeal tumours and 17% with oropharyngeal tumours

History
Ask about symptoms of reflux disease: Oesophageal pathology such as hiatus hernia and gastrooesophageal reflux disease have been reported to cause referred otalgia. Ask about symptoms arising from the neck: Cervical spine pathology such as osteoarthritis can cause otalgia owing to irritation of C1 and C2 nerve roots (retroauricular or infra-auricular pain, which is
constant and often related to changes in neck position).

Examinatio n
Examine the ears: Ear examination is vital to rule out otological conditions Examine the nose: Examination of the nose may reveal signs of chronic rhinosinusitis such as an inflamed nasal mucosa, polyps, mucopus within the sinus ostia or a primary sinonasal tumour.

Examinatio n
Examine the teeth and oropharynx: Examination of the teeth and oral cavity can identify dental caries, aphthous ulceration, loose fillings, dental abscess or malocclusion. Dental maloccusion is identified when there is a significant bite discrepancy between the upper and lower incisors. Intra-oral swelling over tooth apex and gingival margin is seen in cases of acute apical abscess and periodontal abscess, respectively. Percussion tenderness can be demonstrated in cases of apical periodontitis, apical abscess, periodontal abscess and pericoronitis. Inspect the oropharynx to rule out tonsillitis, peritonsillar abscess or a pharyngeal tumour

Examinatio n
Examine the neck Neck examination may identify infective or neoplastic lesions of the parotid gland (parotitis and neoplasm), cervical nodes (lymphadenitis and metastatic cancer) or thyroid abnormalities (thyroiditis and neoplasm). Flexible nasendoscopy examination If the earlier examinations fail to identify a cause of otalgia, a flexible nasendoscopy examination is required to assess the nasopharynx, hypopharynx and larynx

Examinatio n
Examine the cranial nerves Cranial nerve (CN) examination is vital and should be compared bilaterally. Abnormalities of V3 can occur in lesions affecting the anterior tongue and floor of mouth. An altered sensation in the distribution of V2 is seen in cancers involving the maxillary antrum, ethmoids and nasopharynx. Tumours in this region can also affect CN IIIrd, IVth and VIth. VI th nerve involvement is also demonstrated in lesions involving the cavernous sinus and petrous apex (e.g. petrous apicitis in Gradenigos syndrome).

Examinatio n
A lower motor neuron VII nerve palsy can be seen in patients with malignant parotid tumours. A delayed or absent corneal reflex can be an early sign of retrocochlear pathology such as vestibular schwannoma. Dysfunction of the lower CNs (IX, X, XI and XII) can occur in primary or metastatic tumours of the pharynx, larynx and glomus tumours eroding the skull base.

Examinatio n
Examine the temporomandibular joint (TMJ) Palpate the TMJ for tenderness or sounds on mouth opening. The temporalis and masseter muscles should also be palpated for localised tenderness or muscle spasm. Intra-oral palpation of the pterygoid muscles can elicit tenderness in TMD. The lateral pterygoid is palpated above and behind the upper molars, whereas the medial pterygoid is felt in the inner aspect of the lowest corner of the jaw. Tenderness over the pterygoids is the most consistent finding in TMD. Intra-oral palpation of the coronoid process of the mandible can also elicit pain in TMD.

Although approximately 4% of the population is thought to have an elongated styloid process, only a small percentage (between 4 and 10.3%) of this group is thought to be actually symptomatic Eagles syndrome should be suspected in the presence of persistent throat pain that is triggered or exacerbated by head rotations, lingual movements, swallowing or chewing. Diagnosis is made both by radiological and physical examination. Palpation of the styloid process in the tonsillar fossa is indicative of an elongated styloid process, whereas processes with normal length are generally not palpable. Palpation of the tip of the styloid should exacerbate existing symptoms. Subsidence of the patients symptoms after lidocaine infiltration may also support the diagnosis

Examinatio n

Examinatio n
Examine the cervical spine Patients with a history of osteoarthritis should have their cervical spine examined to identify focal joint tenderness, limited neck movements or paraspinal muscle spasm. Patients with cervical myofascial pain syndrome demonstrate focal muscle tenderness but normal motor and sensory function

Exam. Summary
When the ear examination is normal The basic examination should include inspection of the nose and oropharynx, palpation of the head and neck, and examination of the cranial nerves. The gingiva should be inspected and palpated and the teeth inspected and percussed to assess tenderness The physician should palpate the TMJ for tenderness and crepitus as the patient opens and closes the mouth.

Hypertrophic linear lesion (linea alba) on the buccal mucosa at the occlusal plane, consistent with bruxism

Typical appearances of pericoronitis of lower wisdom tooth

Discharging sinus due to chronic apical periodontal abscess or chronic apical periodontitis

What investigations should you consider?

Investigations
Orthopantomogram Clinical evidence of dental pathology such as caries teeth, periodontitis, malocclusion or dental abscess should prompt radiographic imaging. Orthopantomograms play an integral role in the diagnosis and treatment of patients with dental disorders.

Investigations
Barium swallow Oesophageal disorders (hiatus hernia, reflux disease and malignancy are recognised causes of referred otalgia. Therefore, otalgia associated with dysphagia and a normal ENT Head and Neck examination should initially be investigated with a barium swallow. However, a negative test should not be completely relied upon. This is because a barium swallow concentrates on the oesophagus and has limited value in identifying pharyngeal pathology especially in the postcricoid region. If clinical suspicion persists, patients should progress to a panendoscopy.

Investigations
Panendoscopy and biopsy Patients identified with suspicious malignant lesions in the upper aerodigestive tract should undergo a panendoscopy and biopsy to confirm the clinical diagnosis and to aid in disease staging. Attention should also be focussed to specific areas such as the post-nasal space, tongue base, tonsillar fossa and hypopharynx

Investigations
Radiological imaging Referred otalgia with no obvious cause should be investigated with a CT or magnetic resonance imaging (MRI) of the head and neck to assess areas that are not easily evaluated by physical examination. Referred otalgia secondary to tumours involving the tongue base or palatine tonsil may not be clinically evident until late in the disease, and therefore highrisk patients should undergo early imaging to rule out malignant pathology. Cranial nerve palsies also warrant CT imaging of the head and neck including chest where appropriate.

Clinical recommendation
Magnetic resonance imaging and nasolaryngoscopy should be considered for patients with otalgia who have a normal ear examination and who have signs, symptoms, or risk factors for tumor (e.g., tobacco or alcohol use, age older than 50 years). Young (i.e., younger than 40 years), otherwise healthy adults with otalgia and a normal ear examination can be treated symptomatically. Patients older than 50 years with unexplained otalgia and a normal ear examination should have an erythrocyte sedimentation rate measurement to help rule out temporal arteritis

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What treatment should you offer?

Treatment
One of the pitfalls of managing patients with otalgia with no obvious cause is overlooking a malignant process within the head and neck. Management of referred otalgia is directed to the underlying cause.

Treatment
Dental disorders The most common cause of referred otalgia is caries teeth particularly involving the mandibular molars. Progressive decay can result in acute pulpitis followed by a dental abscess. Patients with dental disorders should promptly be referred to a dentist

Treatment
Temporomandibular joint dysfunction The vast majority of cases of TMD can be managed . In a retrospective review of 450 patients diagnosed with TMD, 75% of cases were successfully managed with conservative measures such as analgesia, heat massages and occlusal splints. In cases where TMD is associated with states of anxiety, depression or stress, the use of tricyclic antidepressants is indicated

Treatment
Laryngopharyngeal reflux (LPR) Laryngopharyngeal reflux has been linked to a variety of ENT disorders such as laryngitis, pharyngitis, chronic cough and globus-type symptoms. Antireflux therapy proved to be beneficial in patients with reflux-related ENT disorders. Other treatment modalities include lifestyle modifications (avoiding heavy meals and reducing smoking caffeine intake) and or alginate barrier formulations

Treatment
Cervical spine diseases In review of 123 patients, Jaber et al. reported that the most common cervical spine condition causing referred otalgia were degenerative diseases. Once diagnosed, these patients should be referred for appropriate physiotherapy

Treatment
Neuralgia Neuralgic pain manifesting as otalgia can occur in the distribution of the trigeminal, glossopharyngeal, geniculate or sphenopalatine nerves. Anticonvulsant drugs have been frequently used for chronic neuropathic pain. In a review of randomised controlled trials, carbamazepine was reported to be the most effective drug for trigeminal neuralgia. Surgical intervention for intractable cases is performed in tertiary centres and involves selective rhizotomy or microvascular decompression of the affected nerve.

Treatment
Elongated styloid process (Eagles syndrome) Although controversial, Eagles syndrome is defined as otalgia, facial pain or sore throat secondary to an elongated styloid process or ossified stylohyoid ligament. The evidence to support surgical management is from limited case series describing preoperative CT imaging to confirm the diagnosis followed by a transoral approach to resect the styloid process

Treatment
Sectioning the Sensory Auricular Branch of the Facial Nerve to Treat Recalcitrant Otalgia (to treat
idiopathic neuralgia of the sensory auricular branch of the facial Nerve)

Conclusions

Conclusion
Referred otalgia is a common presenting symptom A complete history followed by a systematic head and neck examination often helps to arrive at the diagnosis Patients with risk factors for malignancy should have a panendoscopy and biopsy of suspicious areas CTMRI imaging should be obtained wherever indicated and is particularly useful to identify rare but sinister causes of otalgia.

Conclusion
Management of referred otalgia should be directed towards the underlying pathology and or referral to the appropriate specialty The most common cause of referred otalgia is dental disease.

References
1. Visvanathan, V. & Kelly, G.: 12 minute consultation:an evidence-based management of referred otalgia. Clin. Otolaryngol. 2010, 35, 409414 2. JOHN W. ELY; MARLAN R. HANSEN; and ELIZABETH C. CLARK: Diagnosis of Ear Pain. American Family Physician 2008, 77(5): 621628. 3. Jane L. Weissman A Pain in the Ear: The Radiology of Otalgia AJNR 1997, 18:16411651 4. D S KIM, P CHEANG, S DOVER, A B DRAKE-LEE: Dental otalgia The Journal of Laryngology & Otology (2007), 121, 11291134

Thank You for Email: kamal375@yahoo.com Attention Homepage: http://www.kfu.edu.sa/ar/Spaces/kaboalhamd/Pages/Home.aspx

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